The 1982 Hastings Center Report raises several important issues from across the spectrum of biomedical ethics that we have been discussing in this class. The most prominent issue raised in the article “When Doctors Should Intervene” by Terrence F. Ackerman is that of how autonomy is affected by illness. According to Ackerman, there are many ways in which illness diminishes autonomy. Illness can make a person mentally incompetent to make decisions, create social pressures that impact a patient’s course of decision making, or cause fear that also impacts a person’s decision making.
Ackerman then goes on to argue that a paternalistic intervention is justified in a situation where an illness impacts autonomy in some way. While I mostly agree with him, I do believe that there need to be some limits on physicians’ intervention in order to protect patients’ autonomy. While it is likely that illness legitimately affects a person in several ways, there is always the possibility that a patient has undergone a legitimate value change and truly, competently, and autonomously wishes to change his or her direction of treatment. Thus, physicians and surrogate decision makers need to be careful when dealing with issues of paternalistic intervention.
Ackerman suggests that the way to deal with these situations is to return control to the patients by explaining the relevant information in such a way that the patient can clearly understand what is going on and can make a decision based on that understanding. This is where I begin to take issue with his argument. One of the most dangerous things a physician can do for a patient’s autonomy is to explain information through different lenses. For example, a patient dealing with diminished autonomy as a result of severe anxiety may still legitimately fear a certain course of treatment even if he or she was not being under the influence of anxiety. However, if a physician was to emphasize the good aspects of the treatment and downplay the negatives to try to get the patient to do what the physician considers to be the best course of action, then in my view, this physician has performed a hard paternalistic intervention that is unjustified.
The framing effect makes it extremely difficult to get information to a patient in an unbiased manner, and it is almost impossible to do so if the information is transmitted verbally. In my opinion, the best way to give information to a patient is to write it out on a paper and give it to the patient to read, and then give the patient the opportunity to ask any questions about his or her condition and plan for treatment.
This whole discussion reminds me of the case of Dax Cowart, which we discussed in class this past week. Cowart’s case was a case of paternalistic intervention by his physicians that he did not want. While the case can be made that the paternalistic intervention was justified on the grounds that he suffered a severe injury that ultimately led him to have depression and unjustifiably want to commit suicide, this was clearly a case of a legitimate value change that coincidentally coincided with a severe medical occurrence that could diminish autonomy. In addition to not accounting for this possibility, Dax’s physicians also failed miserably with their presentation of the information, as they inflicted him with severe pain under the guise of making him better. I would argue that he was worse off due to all of the pain and suffering associated with the treatments for his burns. As Dax’s case makes very clear, physicians need to be careful with their own evaluations of a situation and how they present information to patients about their own situations.
Hi Thomas,
Thank you for a fascinating post. I agree with many of your thoughts on the concept of paternalism, particularly those regarding presenting information to a patient in an unbiased manner. Having a patient read information off of a piece of paper, however, seems like a bit of an extreme way to combat bias. What if the patient can’t read? What if more explanation is necessary in order to obtain a full grasp of the problem at hand, and, furthermore, how is the doctor-patient relationship affected by this? Where I agree that a doctor presenting information to a patient in a verbal manner most likely will always result in bias and potentially lead to paternalism, I do not think that “playing it safe” like this is worth the effects on doctor-patient relationships.
Regarding Dax Cowart’s case, I think that the paternalistic intervention was justified in a different manner. There were really no other options when Dax arrived at the hospital other than to give him treatment. At the time, PAS was not prevalent and had a serious stigma surrounding it (they weren’t even fully aware of the effects of painkillers, let along the technology needed to help Dax commit suicide), and before even thinking about fulfilling his wishes, he needed treatment to get to a point where he could do so as a burn victim. There were many other ridiculous violations of Dax’s autonomy in this case, but I don’t believe that the course of treatment was necessarily one of them. This too, however, warrants your statement regarding physicians’ evaluations of situations, and information could have been presented to Dax related to the reasoning for his treatment if this was the case at the time.
Thanks!
Elisabeth Crusey
Hi Thomas!
I agree with your assertion that “there need to be some limits on physicians’ intervention in order to protect patients’ autonomy”. Physicians have a responsibility to allow their patients to make their own choices. Illness does not mean incompetence. Just because someone is ill, it doesn’t mean they will necessarily exhibit diminished autonomy. “Deciding whether someone is legally competent to make decisions regarding their own treatment requires an assessment of their mental capacity.” (Buchanan) If a patient is deemed mentally competent, they should have the final say in the sort of medical treatment they receive. If a doctor were to disregard a competent patient’s decision, this would be a huge violation of the patient’s right to autonomy. “Patient autonomy is a fundamental, yet challenging, principle of professional medical ethics.” (Murgic et al.)
All patients have external stressors weighing on their decision-making capabilities. This does not mean they are incapable of reasoning or logical thought processes. I agree with your statement that being ill may change a patient’s way of thinking without affecting their competence. Someone who is sick may experience a change of heart, which may affect the way they approach their treatment. However, unless a patient is deemed mentally incompetent, it should not be assumed that they are psychologically inept to handle their medical responsibilities. A psychological assessment should be performed on a patient before disallowing them from being able to make important decisions regarding their treatment.
References
Buchanan, Alec. “Mental Capacity, Legal Competence and Consent to Treatment.” Journal of the Royal Society of Medicine. The Royal Society of Medicine, Sept. 2004. Web. 22 Mar. 2017.
Murgic, Lucija, Philip C. Hébert, Slavica Sovic, and Gordana Pavlekovic. “Paternalism and Autonomy: Views of Patients and Providers in a Transitional (post-communist) Country.” BMC Medical Ethics. BioMed Central, 2015. Web. 22 Mar. 2017.